The first hour of a newborn's life is fraught with difficulty. Recommendations regarding the fundamental issues of resuscitation of these infants are developed and disseminated by the International Liaison Committee on Resuscitation and other organizations. However, these recommendations frequently do not address the needs of the very low birth weight infant and do not address some of the nuances that might lead to improved outcome. Improved organization and teamwork as well as improved monitoring and respiratory support can potentially improve the outcome of these infants.